Overview

The Clinical Care Transitions Manager is responsible for the efficient process and fiscal management of the care coordination process which includes both acute and community case management. This position has oversight of both continuous performance improvement of clinical care transition ensuring that patients receive the right care at the right time and in the right setting. This position manages patient care related organizational projects to ensure efficiency as well as effective management of resources. This position also is responsible for the management of care transition grants, data aggregation and reporting and engaging the clinical team in any continuous performance improvement needed to achieve quality patient care outcomes.

Responsibilities

Maintains, updates, completes and educates to Case Management, Social Services and Care Transitions policies and procedures.

Provides for frontline case management and or social services as needed and or indicated. 

Completes and or delegates follow-up phone calls and coaching calls. Provides interventions based on call outcomes.

Provide case management back-up for Partnership and Medi-Cal patients. Contacts patients pre-op to discuss post hospitalization care.

Provides care transition coordination in the ED and Surgery as needed. Provides education and training to both groups

Interfaces with Medical Directors of the Hospitalist and Emergency Department regarding care coordination, utilization management concerns. Completes UM audits, develops medical necessity reports based on denial data.

Provides daily, weekly and quarterly data reports to Nursing, Medical Staff and Administration metric performance as requested. Directs continuous performance improvement efforts.

Works with the Community Health Clinic, Home Care, and Skilled Nursing as well as Sonoma County social and mental health resources and providers to ensure care transitions are seamless. Works with other providers as needed to facilitate care.

Provides direction, coaching and support to direct reports regarding professional standards, work quality, performance and accountability; collaborates on resolving problems and/or performance gaps; develops annual staff engagement improvement plans; and engages in regular communications (department meetings, one-on-ones, performance feedback, etc.). Also provides mentorship for hospital leaders as requested. 

Leads project Management teams as appropriate; maintaining records, agendas, developing metrics and reporting process improvement efforts as requested.

Qualifications

Education: Graduate of an accredited RN program; BS or MS degree in a healthcare related field preferred. Experience: At least one (1) year leadership experience with 5-7 years of case management. Quality and Utilization Management leadership experience required.Licenses & Certifications: California RN with certification in Case Management, Population Health, Quality or Utilization Management.Required Skills & Knowledge: Excellent interpersonal and coaching skills; strong performance improvement background with proven ability to lead cross departmental teams. Proficient with Excel, Microsoft, Visio, Power Point and other tools used for performance improvement. Knowledgeable of Interqual, pre-operative processing of patients and communication tools.

Compensation

Minimum:

Maximum: